Equitable health services

Almost universal coverage: HIV testing among TB patients in a rural public programme
Chimbindi N, Bärnighausen T and Newell M: International Journal of Tuberculosis and Lung Disease 16(4), May 2012

In this study, the authors collected data as part of a multi-site cross sectional study, Researching Equity in Access to Healthcare (REACH), to examine HIV testing coverage in tuberculosis (TB) patients. They administered a structured questionnaire to 300 patients accessing TB treatment in five rural primary health care clinics in Hlabisa subdistrict, KwaZulu-Natal, South Africa, a high TB and HIV burden area. Results showed high HIV testing rates among TB patients, suggesting that TB-HIV co-infected patients can be managed appropriately for treatment of both infections. The decentralised programme appears largely successful in attaining universal HIV testing in TB patients in this resource-limited setting. However, there is scope for further improvement such as in DOTS delivery, which is a sustainable and effective way of ensuring good adherence to TB treatment, the authors argue. Patients mostly use the closest clinic for both TB treatment and HIV testing, suggesting a receding fear of stigma of HIV. But the small number of patients not using the closest clinic are far less likely to undergo HIV testing, possibly indicating vulnerability expressed both in the location of seeking TB treatment and HIV testing uptake. Policy makers should encourage integration of services and cross-testing in HIV-TB facilities, the authors conclude.

Alternatives to Privatisation: Public Options for Essential Services in the Global South
McDonald DA and Ruiters G: Routledge, 27 February 2012

Those who are against privatisation of public services are often confronted with the objection that there is no alternative. This book takes up that challenge by establishing theoretical models for what does (and does not) constitute an alternative to privatisation, and what might make them ‘successful’, backed up by a comprehensive set of empirical data on public services initiatives in over 40 countries. This is the first such global survey of its kind, providing a rigorous and robust platform for evaluating different alternatives and allowing for comparisons across regions and sectors. The book helps to conceptualise and evaluate what has become an important and widespread movement for better public services in the global South. The contributors explore historical, existing and proposed non-commercialised alternatives for primary health, water/sanitation and electricity. The objectives of the research have been to develop conceptual and methodological frameworks for identifying and analysing alternatives to privatisation, and testing these models against actually existing alternatives on the ground in Asia, Africa and Latin America. Information of this type is urgently required for practitioners and analysts, both of whom are seeking reliable knowledge on what kind of public models work, how transferable they are from one place to another and what their main strengths and weaknesses are.

Alternatives To Privatisation: Public Options For Essential Services In The Global South
McDonald DA and Ruiters G: Routledge, 27 February 2012

Those who are against privatisation of public services are often confronted with the objection that there is no alternative. This book takes up that challenge by establishing theoretical models for what does (and does not) constitute an alternative to privatisation, and what might make them ‘successful’, backed up by a comprehensive set of empirical data on public services initiatives in over 40 countries. This is the first such global survey of its kind, providing a rigorous and robust platform for evaluating different alternatives and allowing for comparisons across regions and sectors. The book helps to conceptualise and evaluate what has become an important and widespread movement for better public services in the global South. The contributors explore historical, existing and proposed non-commercialised alternatives for primary health, water/sanitation and electricity. The objectives of the research have been to develop conceptual and methodological frameworks for identifying and analysing alternatives to privatisation, and testing these models against actually existing alternatives on the ground in Asia, Africa and Latin America. Information of this type is urgently required for practitioners and analysts, both of whom are seeking reliable knowledge on what kind of public models work, how transferable they are from one place to another and what their main strengths and weaknesses are.

An alternative proposal for enhancing developing country access to patented medicines
Sawahel W: Intellectual Property Watch, 10 December 2008

An intellectual property (IP) model intended to preserve the structure of patent protection while adding balance for developing countries, has been proposed to provide incentives for innovators to contribute toward the alleviation of suffering in developing countries in dire need of patented medicines largely owned by rich countries. This IP model, which would increase the role of the World Health Organization (WHO) in the process, was presented recently by Amir Khoury, an intellectual property law and international trade specialist at the law faculty of Tel Aviv University. The proposal would put greater decision-making authority on the use of compulsory licensing to obtain cheaper versions of patented medicines in the hands of the WHO. Currently, that activity occurs under the World Trade Organization.

An assessment of equity in the distribution of non-financial health care inputs across public primary health care facilities in Tanzania
Kuwawenaruwa A; Borghi J; Remme M; Mtei G: International Journal for Equity in Health 16(124) 2017

This paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. It reports a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. The authors administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. The authors found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems.

An Autopsy Study of Maternal Mortality in Mozambique: The Contribution of Infectious Diseases
Menéndez C, Romagosa C, Ismail MR, Carrilho C, Saute F, Osman N, Machungo F, Bardaji A, Quintó L, Mayor A, Naniche D, Dobaño C, Alonso PL, Ordi J: PLoS Medicine 5(2), 19 February 2008

Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. The researchers conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.

An evaluation of infant immunisation in Africa: Is a transformation in progress?
Arevshatian L, Clements CJ and Lwanga SK: Bulletin of the World Health Organisation, International Journal of Public Health, 2007

This paper assesses the progress towards meeting the goals of the African Regional Strategic Plan of the Expanded Programme on Immunisation between 2001 and 2005. These goals include: to interrupt the circulation of wild polio virus in all countries; eliminate maternal and neonatal tetanus in all high-risk districts; 80% of the countries to have reached at least 80% diphtheria-tetanus-pertissus-3 (DTP-3) coverage; and measles to be controlled and eliminated in Southern Africa. The paper finds that although more infants had been immunised by 2005, most of the targets had been missed by at least half of the region’s countries. The authors estimate that DTP-3 coverage increased from 54% in 2000 to 69% in 2004, and as a result the number of non-immunised children declined from 1.4 million in 2002 to 900,000 in 2004. Reported measles cases dropped from 520,000 in 2000 to 316,000 in 2005 and mortality was reduced by approximately 60%. The paper concludes that the rates of immunisation coverage are improving dramatically in the WHO African region. The huge increases in spending on immunisation and the related improvements in programme performance are linked predominantly to increases in donor funding.

An integrated approach to improving the availability and utilisation of tuberculosis healthcare in rural South Africa
Chimbindi NZ, Bärnighausen T and Newell ML: South African Medical Journal 103(4): 237-240, April 2013

The objective of this study was to investigate factors, including uptake of the offer of HIV testing, associated with availability and utilisation of healthcare by TB patients in a rural programme devolved to primary care in Hlabisa sub-district, KwaZulu-Natal. Three hundred TB patients at primary healthcare clinics (PHC) were randomly selected for the study. Most patients (75.2%) received care for a first episode of TB, mainly pulmonary. Nearly all (94.3%) were offered an HIV test during their current TB treatment episode, patients using their closest clinic being substantially more likely to have been offered HIV testing than those not using their closest clinic. About one-fifth (20.3%) of patients did not take medication under observation, and 3.4% reported missing taking their tablets at some stage. Average travelling time to the clinic and back was 2 hours, most patients (56.8%) using minibus taxis. The study demonstrates high HIV testing rates among TB patients and the authors suggest appropriate management of HIV-TB co-infected patients.

Angola to boost polio eradication programme
IRIN News: 25 January 2011

The Angolan government is preparing to renew efforts to eradicate polio with support from global partners, including the Bill and Melinda Gates Foundation, which has made polio eradication its top priority. Angola succeeded in stamping out polio for three consecutive years at the beginning of the century, but a strain of the virus prevalent in India reappeared in 2005 and has since spread to the neighbouring countries of Namibia, the Democratic Republic of Congo and the Republic of Congo. In 2010, 32 people in Angola contracted the highly infectious and incurable disease. Angola's health system, still recovering from years of war, only managed to fully vaccinate 35% of infants in 2009. According to UNICEF, supplementary immunisation campaigns have been beset by a lack of manpower, technical capacity and planning, particularly in Luanda where most of the polio cases in recent years have been concentrated. Since the war, Luanda's population has boomed, and many of the rural migrants live in cramped conditions with little access to safe water and sanitation. Such conditions are ideal for spreading polio, which is transmitted through faecal-oral contact. During a meeting on 24 January 2011 with Anthony Lake, UNICEF Executive Director, and Tachi Yamada, president of The Gates Foundation's global health programme, José Eduardo dos Santos, Angola’s president, reaffirmed the government's commitment to eradicating polio. The government's strategy consists of better surveillance of new polio cases, accelerated routine immunisation of children, better-quality vaccination campaigns and a campaign to promote household water treatment and hygiene.

Anti-fakes bill threatens access to generics
Kimani D: The East African, 8 September 2008

Kenyan health activists last week slammed the country’s proposed anti-counterfeiting law, saying that provisions had been slipped into it to prevent the importation of cheap generic medicines. They say the Kenya Anti-Counterfeit Bill 2008 does not distinguish between medicines and ordinary items such items as pens, DVDs and batteries, and also contravenes the provisions of the 2001 Industrial Property Act (IPA), which paved the way for the widespread use of generic ARVs to manage HIV/AIDS. The Bill contains various ambiguities, which, if misinterpreted or abused, would be detrimental to the government’s ongoing efforts to ensure access to essential medicines for all Kenyans. These ambiguities should be addressed in order to ensure that interested parties, including the multinational pharmaceutical industry, do not misuse the Bill as a front to discriminate against more affordable generic competition.

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